EMEND PRODUCT MONOGRAPH. aprepitant capsules. 80 and 125 mg. Neurokinin 1 (NK 1 ) receptor antagonist

Transcription

1 PRODUCT MONOGRAPH EMEND aprepitant capsules 80 and 125 mg Neurokinin 1 (NK 1 ) receptor antagonist Merck Canada Inc route Transcanadienne Kirkland, QC H9H 4M7 Canada Date of Revision: January 22, Submission Control No: and internal filing March 05, 2018 EMEND (aprepitant capsules) Page 1 of 40

2 Table of Contents PART I: HEALTH PROFESSIONAL INFORMATION...3 SUMMARY PRODUCT INFORMATION...3 INDICATIONS AND CLINICAL USE...3 CONTRAINDICATIONS...3 WARNINGS AND PRECAUTIONS...4 ADVERSE REACTIONS...5 DRUG INTERACTIONS...10 DOSAGE AND ADMINISTRATION...13 OVERDOSAGE...15 ACTION AND CLINICAL PHARMACOLOGY...16 STORAGE AND STABILITY...18 DOSAGE FORMS, COMPOSITION AND PACKAGING...19 PART II: SCIENTIFIC INFORMATION...20 PHARMACEUTICAL INFORMATION...20 CLINICAL TRIALS...20 DETAILED PHARMACOLOGY...31 TOXICOLOGY...33 REFERENCES...36 PART III: CONSUMER INFORMATION...38 EMEND (aprepitant capsules) Page 2 of 40

3 EMEND aprepitant capsules PART I: HEALTH PROFESSIONAL INFORMATION SUMMARY PRODUCT INFORMATION Route of Administration oral Dosage Form / Strength Capsule/ 80 mg, 125 mg Clinically Relevant Non-Medicinal Ingredients For a complete listing see DOSAGE FORMS, COMPOSITION AND PACKAGING section. INDICATIONS AND CLINICAL USE EMEND (aprepitant), in combination with a 5-HT 3 antagonist class of antiemetics and dexamethasone, is indicated for the: 1. prevention of acute and delayed nausea and vomiting due to highly emetogenic cancer chemotherapy 2. prevention of nausea and vomiting in women due to treatment with moderately emetogenic cancer chemotherapy. Geriatrics ( 65 years of age): In clinical studies, the efficacy and safety of EMEND in the elderly ( 65 years) were comparable to those seen in younger patients (<65 years). No dosage adjustment is necessary in elderly patients. Pediatrics (<18 years of age): No data available. CONTRAINDICATIONS Patients who are hypersensitive to this drug or to any ingredient in the formulation. For a complete listing, see the DOSAGE FORMS, COMPOSITION AND PACKAGING section of the product monograph. EMEND should not be used concurrently with pimozide, terfenadine, astemizole, or cisapride. Inhibition of cytochrome P450 isoenzyme 3A4 (CYP3A4) by aprepitant could result in elevated plasma concentrations of these drugs, potentially causing serious or lifethreatening reactions (see DRUG INTERACTIONS). EMEND (aprepitant capsules) Page 3 of 40

4 WARNINGS AND PRECAUTIONS Serious Warnings and Precautions Drug interactions with: Medicinal products, including chemotherapeutic agents, that are metabolized through CYP3A4 (see DRUG INTERACTIONS) Warfarin (see DRUG INTERACTIONS) Hormonal contraception (see DRUG INTERACTIONS) Drug Interactions CYP3A4 substrates: EMEND is a moderate inhibitor of CYP3A4. Caution should be used when EMEND is co-administered with CYP3A4 substrates, including chemotherapeutic agents (see DRUG INTERACTIONS). Serious post-marketing reports of neurotoxicity, a potential adverse reaction of ifosfamide, have been reported in patients after EMEND and ifosfamide co-administration. Caution and careful monitoring are advised. Refer to IFEX (ifosfamide for injection) product monograph. (see ADVERSE REACTIONS / Post-Market Adverse Drug Reactions and DRUG INTERACTIONS). Warfarin: Co-administration of EMEND with warfarin may cause a clinically significant decrease in the INR. In patients on chronic warfarin therapy, the INR should be closely monitored in the 2-week period, particularly at 7 to 10 days, following initiation of the 3-day regimen of EMEND with each chemotherapy cycle (see DRUG INTERACTIONS). Hormonal contraception: EMEND may reduce the efficacy of hormonal contraception. Alternative or backup methods should be used during and for 1 month following the last dose of EMEND (see DRUG INTERACTIONS). Special Populations Pregnant Women: Reproductive studies have been performed in rats and rabbits at doses up to 1.5 times the systemic exposure at the adult human dose and have revealed no evidence of impaired fertility or harm to the fetus due to aprepitant. However, there are no adequate and well-controlled studies in pregnant women; therefore, EMEND is not recommended for use during pregnancy unless clearly necessary. Nursing Women: Aprepitant is excreted in the milk of lactating rats. It is not known whether this drug is excreted in human milk; therefore, breastfeeding is not recommended during treatment with EMEND. Pediatrics (<18 years of age): Safety and effectiveness of EMEND in pediatric patients have not been established. EMEND (aprepitant capsules) Page 4 of 40

5 Geriatrics ( 65 years of age): In 2 well-controlled clinical studies, of the total number of patients (N=544) treated with EMEND, 31% were 65 and over, while 5% were 75 and over. No overall differences in safety or effectiveness were observed between these subjects and younger subjects. Greater sensitivity of some older individuals cannot be ruled out. Dosage adjustment in the elderly is not necessary. ADVERSE REACTIONS Clinical Trial Adverse Experiences The overall safety of aprepitant was evaluated in approximately 6500 individuals. Highly Emetogenic Chemotherapy (HEC) In 2 well-controlled clinical trials in patients receiving cisplatin-based chemotherapy, 544 patients were treated with aprepitant during Cycle 1 of chemotherapy and 413 of these patients continued into the Multiple-Cycle extension for up to 6 cycles of chemotherapy. EMEND was given in combination with ondansetron and dexamethasone and was generally well tolerated. Most adverse experiences reported in these clinical studies were described as mild to moderate in intensity. In Cycle 1, clinical adverse experiences were reported in approximately 74% of patients treated with the aprepitant regimen compared with approximately 72% of patients treated with standard therapy. Table 1 shows the percent of patients with clinical adverse experiences reported at an incidence 3%. EMEND (aprepitant capsules) Page 5 of 40

6 Table 1 All adverse experiences, regardless of causality (incidence 3%), occurring in patients receiving highly emetogenic chemotherapy who were treated with the aprepitant regimen for chemotherapy induced nausea and vomiting (CINV) in clinical studies (cycle 1) Aprepitant Regimen Standard Therapy General Disorders and Administration Site Conditions N=544 % N=550 % Asthenia Fatigue Pyrexia Gastrointestinal Disorders Abdominal Pain Abdominal Pain Upper Constipation Diarrhea Dyspepsia Gastritis Nausea Stomatitis Vomiting Ear and Labyrinth Disorders Tinnitus Metabolism and Nutrition Disorders Decreased appetite Dehydration Nervous System Disorders Dizziness Headache Psychiatric Disorders Insomnia Respiratory, Thoracic and Mediastinal Disorders Hiccups In addition, isolated cases of serious adverse experiences, regardless of causality, of bradycardia, disorientation, and perforating duodenal ulcer were reported in highly emetogenic CINV clinical studies. Moderately Emetogenic Chemotherapy (MEC) During Cycle 1 of 2 moderately emetogenic chemotherapy studies, 868 patients were treated with the aprepitant regimen and 686 of these patients continued into extensions for up to 4 cycles of chemotherapy. In the combined analysis of Cycle 1 data for these 2 studies, adverse experiences were reported in approximately 69% of patients treated with the aprepitant regimen compared with approximately 72% of patients treated with standard therapy. EMEND (aprepitant capsules) Page 6 of 40

7 In the combined analysis of Cycle 1 data for these 2 studies, the adverse experience profile in both moderately emetogenic chemotherapy studies was generally comparable to the highly emetogenic chemotherapy studies. Table 2 shows the percent of patients with clinical adverse experiences reported at an incidence 3%. Table 2 All adverse experiences, regardless of causality (incidence 3%), occurring in patients receiving moderately emetogenic chemotherapy who were treated with the aprepitant regimen for CINV in clinical studies (cycle 1) Aprepitant Regimen Standard Therapy N=868 % N=846 % Blood and Lymphatic System Disorders Neutropenia Metabolism and Nutrition Disorders Decreased appetite Psychiatric Disorders Insomnia Nervous System Disorders Dizziness Headache Gastrointestinal Disorders Constipation Diarrhea Dyspepsia Nausea Stomatitis Skin and Subcutaneous Tissue Disorders Alopecia General Disorders and General Administration Site Conditions Asthenia Fatigue In a combined analysis of these two studies, isolated cases of serious adverse experiences were similar in the two treatment groups. Additional Clinical Trial Adverse Experiences (>0.5% and greater than standard therapy), Regardless of Causality, Occurring in Patients Receiving Highly and Moderately Emetogenic Chemotherapy Blood and lymphatic system disorders: anemia, febrile neutropenia, neutropenia, thrombocytopenia. Cardiac disorders: myocardial infarction, palpitations, tachycardia. EMEND (aprepitant capsules) Page 7 of 40

8 Eye disorders: conjunctivitis. Gastrointestinal disorders: dry mouth, dysphagia, epigastric discomfort, eructation, flatulence, gastroesophageal reflux disease, odynophagia, salivary hypersecretion. General disorders and administrative site conditions: chest pain, edema peripheral, malaise, pain. Infections and infestations: oral candidiasis, pharyngitis, septic shock. Investigations: weight decreased. Metabolism and nutrition disorders: diabetes mellitus, hypokalemia. Musculoskeletal and connective tissue disorders: musculoskeletal pain. Nervous system disorders: dysgeusia, peripheral neuropathy, peripheral sensory neuropathy. Psychiatric disorders: anxiety, confusion, depression. Renal and urinary disorders: dysuria, renal insufficiency. Respiratory, thoracic and mediastinal disorders: cough, dyspnea, oropharyngeal pain, pneumonitis, pulmonary embolism, respiratory insufficiency, vocal disturbance. Skin and subcutaneous tissue disorders: hyperhidrosis, acne, rash. Vascular disorders: deep venous thrombosis, flushing, hot flush, hypertension, hypotension. Other Clinical Trials Stevens-Johnson syndrome was reported as a serious adverse experience in a patient receiving aprepitant with cancer chemotherapy in another CINV study. Abnormal Hematologic and Clinical Chemistry Findings Table 3 shows the percent of patients with laboratory adverse experiences reported at an incidence 3% in patients receiving highly emetogenic chemotherapy. EMEND (aprepitant capsules) Page 8 of 40

9 Table 3 All laboratory abnormalities, regardless of causality (incidence 3%), occurring in patients receiving highly emetogenic chemotherapy who were treated with the aprepitant regimen for CINV in clinical studies (cycle 1) Aprepitant Regimen Standard Therapy N=544 % N=550 % ALT increased Blood urea increased Blood creatinine increased Protein urine present Table 4 shows the percent of patients with laboratory adverse experiences reported at an incidence 3% in patients receiving moderately emetogenic chemotherapy. Table 4 Percent of Patients Receiving Moderately Emetogenic Chemotherapy with Laboratory Adverse Experiences (Incidence 3%) Cycle 1 Aprepitant Regimen (N=868) Standard Therapy (N=846) Neutrophil Count Decreased White Blood Cell Count Decreased Other Abnormal Hematological and Clinical Chemistry Findings Observed in Clinical Trials The following additional laboratory adverse experiences, regardless of causality, were reported in patients treated with aprepitant regimen: AST increased, blood alkaline phosphatase increased, blood glucose increased, blood sodium decreased, white blood cell count increased, red blood cell urine positive, white blood cell urine positive. The adverse experiences of increased AST and ALT were generally mild and transient. The adverse experience profiles in the Multiple-Cycle extensions of Highly and Moderately Emetogenic Chemotherapy studies for up to 6 cycles of chemotherapy were generally similar to those observed in Cycle 1. Post-Market Adverse Drug Reactions Regardless of causality with EMEND, the following adverse events have been reported rarely or very rarely and occur with multiple confounding factors: loss of consciousness, depressed level of consciousness, convulsion, somnolence, paresthesia, syndrome of inappropriate antidiuretic hormone, hallucination, pruritus, rash, urticaria, Stevens-Johnson syndrome/toxic epidermal necrolysis, and hypersensitivity reactions including anaphylactic reactions. Serious post-marketing events of neurotoxicity, a potential adverse reaction of ifosfamide, have been reported after oral aprepitant and ifosfamide co-administration, including acute psychosis, encephalopathy, toxic encephalopathy, delirium, convulsion, decreased level of consciousness and hallucination (see DRUG INTERACTIONS). EMEND (aprepitant capsules) Page 9 of 40

10 DRUG INTERACTIONS Serious Drug Interactions EMEND should be used with caution in patients receiving concomitant medicinal products that are primarily metabolized through CYP3A4 and CYP2C9, including chemotherapy agents. Inhibition of CYP3A4 by aprepitant could result in elevated plasma concentrations of these concomitant medicinal products. Induction of CYP2C9 by aprepitant could result in decreased plasma concentrations of these concomitant medicinal products (see CONTRAINDICATIONS and Drug-Drug Interactions below). The effect of EMEND on the pharmacokinetics of orally administered CYP3A4 substrates is greater than the effect of EMEND on the pharmacokinetics of intravenously administered CYP3A4 substrates. Coadministration of EMEND with warfarin results in decreased prothrombin time, reported as International Normalized Ratio (INR). In patients on chronic warfarin therapy, the prothrombin time (INR) should be closely monitored in the 2-week period, particularly at 7 to 10 days, following initiation of the 3-day regimen of EMEND with each chemotherapy cycle (see Drug-Drug Interactions below ). The efficacy of hormonal contraceptives during and for 28 days after administration of EMEND may be reduced. Alternative or back-up methods of contraception should be used during treatment with EMEND and for 1 month following the last dose of EMEND (see Drug-Drug Interactions below ). Overview Aprepitant is a substrate, a moderate inhibitor, and an inducer of CYP3A4. Aprepitant is also an inducer of CYP2C9. Chronic continuous use of EMEND is not recommended because it has not been studied and because the drug interaction profile may change during chronic dosing. Effect of aprepitant on the pharmacokinetics of other agents As a moderate inhibitor of CYP3A4, aprepitant can increase plasma concentrations of coadministered medicinal products that are metabolized through CYP3A4. EMEND may increase the plasma concentration of orally administered CYP3A4 substrates to a greater extent than if the substrate was administered intravenously. Aprepitant has been shown to induce the metabolism of S(-) warfarin and tolbutamide, which are metabolized through CYP2C9. Coadministration of EMEND with these drugs or other drugs that are known to be metabolized by CYP2C9, such as phenytoin, may result in lower plasma concentrations of these drugs. EMEND (aprepitant capsules) Page 10 of 40

11 Effect of other agents on the pharmacokinetics of aprepitant Aprepitant is a substrate for CYP3A4; therefore, coadministration of EMEND with drugs that inhibit CYP3A4 activity may result in increased plasma concentrations of aprepitant. Consequently, concomitant administration of EMEND with strong CYP3A4 inhibitors (e.g., ketoconazole, itraconazole, nefazodone, troleandomycin, clarithromycin, ritonavir, nelfinavir) should be approached cautiously. Moderate CYP3A4 inhibitors (e.g., diltiazem) resulted in a 2- fold increase in plasma concentrations of aprepitant; therefore, concomitant administration should also be approached with caution. Aprepitant is a substrate for CYP3A4; therefore, coadministration of EMEND with drugs that strongly induce CYP3A4 activity (e.g., rifampin, carbamazepine, phenytoin) may result in reduced plasma concentrations of aprepitant that may result in decreased efficacy of EMEND. Drug-Drug Interactions Chemotherapeutic agents: Chemotherapy agents that are known to be metabolized by CYP3A4 include docetaxel, paclitaxel, etoposide, irinotecan, ifosfamide, imatinib, vinorelbine, vinblastine and vincristine. In clinical studies, EMEND was administered commonly with etoposide, vinorelbine, paclitaxel and cyclophosphamide. The doses of these agents were not adjusted to account for potential drug interactions. In separate pharmacokinetic studies, EMEND did not influence the pharmacokinetics of IV administered vinorelbine or docetaxel. However, EMEND may increase the plasma concentration of oral CYP3A4 substrates to a greater extent than if the substrates were administered intravenously. No additional drug-drug interaction studies with chemotherapeutic agents metabolized by CYP3A4 were carried out. Serious post-marketing events of neurotoxicity, a potential adverse reaction of ifosfamide, have been reported in patients after EMEND and ifosfamide co-administration. Refer to IFEX (ifosfamide for injection) product monograph. Caution and careful monitoring are advised in patients receiving chemotherapy agents metabolized by CYP3A4, particularly those that were not studied in the clinical trials. (see WARNINGS AND PRECAUTIONS). Established or Potential Drug-Drug Interactions: Proper name Ref Effect Clinical comment pimozide T pimozide concentration terfenadine T terfenadine concentration Astemizole T astemizole concentration Potentially causing serious or life-threatening reactions. Potentially causing serious or life-threatening reactions. Potentially causing serious or life-threatening reactions. EMEND (aprepitant capsules) Page 11 of 40

12 Proper name Ref Effect Clinical comment Cisapride T cisapride concentration Warfarin CT Warfarin concentration INR tolbutamide CT tolbutamide concentration Phenytoin T phenytoin concentration dexamethasone CT dexamethasone concentration methylprednisolone CT methylprednisolone concentration hormone contraceptives with all routes of administration CT hormone concentration Midazolam oral and IV CT midazolam concentration ketoconazole CT aprepitant concentration Potentially causing serious or life-threatening reactions. In patients on chronic warfarin therapy, the INR should be closely monitored in the 2- week period, particularly at 7 to 10 days, following initiation of the 3-day regimen of EMEND with each chemotherapy cycle (see WARNINGS AND PRECAUTIONS and DETAILED PHARMACOLOGY). Aprepitant induces the metabolism of drug metabolized by CYP2C9 (see DETAILED PHARMACOLOGY). Aprepitant induces the metabolism of drug metabolized by CYP2C9. The usual oral dexamethasone doses should be reduced by approximately 50% when coadministered with EMEND, to achieve exposures of dexamethasone similar to those obtained when it is given without EMEND (see DETAILED PHARMACOLOGY). The usual IV methylprednisolone dose should be reduced by approximately 25%, and the usual oral methylprednisolone dose should be reduced by approximately 50% when coadministered with EMEND, to achieve exposures of methylprednisolone similar to those obtained when it is given without EMEND (see DETAILED PHARMACOLOGY). The efficacy of hormonal contraceptives during and for 28 days after administration of EMEND may be reduced. Alternative or back-up methods of contraception should be used during treatment with EMEND and for 1 month following the last dose of EMEND (see WARNINGS AND PRECAUTIONS and DETAILED PHARMACOLOGY). The potential effects of increased plasma concentrations of midazolam or other benzodiazepines metabolized via CYP3A4 (alprazolam, triazolam) should be considered when coadministering these agents with EMEND (see DETAILED PHARMACOLOGY). Concomitant administration of EMEND with strong CYP3A4 inhibitors should be approached cautiously (see DETAILED PHARMACOLOGY). EMEND (aprepitant capsules) Page 12 of 40

13 Proper name Ref Effect Clinical comment Rifampin CT aprepitant concentration Diltiazem CT aprepitant and diltiazem concentration paroxetine CT aprepitant and paroxetine concentration Legend: CT = Clinical Trial; T = Theoretical Coadministration of EMEND with drugs that induce CYP3A4 activity may result in reduced plasma concentrations and decreased efficacy of EMEND (see DETAILED PHARMACOLOGY). No clinically meaningful changes in ECG, heart rate, or blood pressure beyond those changes induced by diltiazem alone (see DETAILED PHARMACOLOGY). See DETAILED PHARMACOLOGY. 5-HT 3 antagonists: In clinical drug interaction studies, aprepitant did not have clinically important effects on the pharmacokinetics of ondansetron administered intravenously, granisetron administered orally, or hydrodolasetron (the active metabolite of dolasetron) following oral administration of dolasetron. P-glycoprotein transporter substrates: EMEND is unlikely to interact with drugs that are substrates for the P-glycoprotein transporter, as demonstrated by the lack of interaction of EMEND with digoxin in a clinical drug interaction study. Drug-Food Interactions EMEND may be administered with or without food. Drug-Herb Interactions Interactions with herbal products have not been established. Drug-Laboratory Interactions Interactions with laboratory tests have not been established. DOSAGE AND ADMINISTRATION Dosing Consideration EMEND is indicated for use for a maximum of 3 consecutive days per chemotherapy cycle. EMEND has not been demonstrated to be effective as a single anti-emetic agent and must be administered with other anti-emetic agents. EMEND (aprepitant capsules) Page 13 of 40

14 Recommended Dose and Dosage Adjustment The recommended dose of EMEND is 125 mg orally 1 hour prior to chemotherapy treatment (Day 1) and 80 mg once daily in the morning on Days 2 and 3. Recommended dosing for the prevention of nausea and vomiting associated with cisplatin-based highly emetogenic cancer chemotherapy: Day 1 Day 2 Day 3 Day 4 EMEND * 125 mg orally 80 mg orally 80 mg orally none Dexamethasone** 12 mg orally 8 mg orally 8 mg orally 8 mg orally 5-HT 3 antagonist See the package insert for the selected 5-HT 3 antagonist for appropriate dosing information. none none none * EMEND was administered orally 1 hour prior to chemotherapy treatment on Day 1 and in the morning on Days 2 and 3. ** Dexamethasone should be administered 30 minutes prior to chemotherapy treatment on Day 1 and in the morning on Days 2 through 4. The dose of dexamethasone accounts for drug interactions. Increasing the dose of dexamethasone is not recommended (see DRUG INTERACTIONS). For highly emetogenic chemotherapy, there is only limited efficacy data with EMEND in combination with oral ondansetron or other 5-HT 3 antagonist class of antiemetics and dexamethasone. In the highly emetogenic chemotherapy clinical trials, the 5-HT 3 antagonist studied was ondansetron administered by the intravenous route. However, the dose used was 32 mg and this is no longer a recommended dose due to the dose-dependent risk of QTc prolongation (see the package insert for ondansetron for additional details). Recommended dosing for the prevention of nausea and vomiting associated with moderately emetogenic cancer chemotherapy: Day 1 Day 2 Day 3 EMEND * 125 mg orally 80 mg orally 80 mg orally Dexamethasone** 12 mg orally none none 5-HT 3 antagonist See the package insert for the selected 5-HT 3 antagonist for appropriate dosing information. none none * EMEND was administered orally 1 hour prior to chemotherapy treatment on Day 1 and in the morning on Days 2 and 3. ** Dexamethasone should be administered 30 minutes prior to chemotherapy treatment on Day 1. The dose of dexamethasone accounts for drug interactions. Increasing the dose of dexamethasone is not recommended (see DRUG INTERACTIONS). For moderately emetogenic chemotherapy, there is only limited efficacy data with EMEND in combination with other 5-HT 3 antagonist class of antiemetics and dexamethasone. In the moderately emetogenic clinical trials, the 5-HT 3 antagonist studied was ondansetron administered by the oral route. EMEND (aprepitant capsules) Page 14 of 40

15 See DRUG INTERACTIONS for additional information on the administration of EMEND with corticosteroids. Refer to each product's respective Product Monograph for additional information on coadministered antiemetic agents. EMEND may be taken with or without food. No dosage adjustment is necessary based on age, gender, race or Body Mass Index (BMI). No dosage adjustment is necessary for patients with severe renal insufficiency (creatinine clearance <30 ml/min) or for patients with end stage renal disease undergoing hemodialysis. No dosage adjustment is necessary for patients with mild to moderate hepatic insufficiency (Child-Pugh score 5 to 9). There are no clinical data in patients with severe hepatic insufficiency (Child-Pugh score >9). OVERDOSAGE For management of a suspected drug overdose, contact your regional Poison Control Centre. No specific information is available on the treatment of overdosage with EMEND. Single doses up to 600 mg of aprepitant were generally well tolerated in healthy subjects. Aprepitant was generally well tolerated when administered as 375 mg once daily for up to 42 days to patients in non-cinv studies. In 33 cancer patients, administration of a single 375-mg dose of aprepitant on Day 1 and 250 mg once daily on Days 2 to 5 was generally well tolerated. Drowsiness and headache were reported in one patient who ingested 1440 mg of aprepitant. In the event of overdose, EMEND should be discontinued and general supportive treatment and monitoring should be provided. Because of the antiemetic activity of aprepitant, drug-induced emesis may not be effective. Aprepitant cannot be removed by hemodialysis. EMEND (aprepitant capsules) Page 15 of 40

16 ACTION AND CLINICAL PHARMACOLOGY Mechanism of Action Aprepitant has a unique mode of action; it is a selective high affinity antagonist at human substance P neurokinin 1 (NK 1 ) receptors. Counter-screening assays showed that aprepitant was at least 3,000-fold selective for the NK 1 receptor over other enzyme, transporter, ion channel and receptor sites including the dopamine and serotonin receptors that are targets for existing chemotherapy induced nausea and vomiting (CINV) therapies. NK 1 -receptor antagonists have been shown pre-clinically to inhibit emesis induced by cytotoxic chemotherapeutic agents, such as cisplatin, via central actions. Preclinical and human Positron Emission Tomography (PET) studies with aprepitant have shown that it is brain penetrant and occupies brain NK 1 receptors. However, the relationship between NK 1 receptor occupancy and the clinical efficacy of aprepitant has not been established. Preclinical studies show that aprepitant has a long duration of central activity, inhibits both the acute and delayed phases of cisplatininduced emesis, and augments the antiemetic activity of the 5-HT 3 -receptor antagonist ondansetron and the corticosteroid dexamethasone against cisplatin-induced emesis. Pharmacokinetics Table 6 Summary of pharmacokinetic parameters of EMEND in healthy subjects C max (μg/ml) AUC 0 24hr (μg hr/ml) Day 1 oral dose aprepitant 125 mg Day 3 oral dose aprepitant 80 mg Absorption: The mean absolute oral bioavailability of aprepitant is approximately 60 to 65% and the mean peak plasma concentration (C max ) of aprepitant occurred at approximately 4 hours (T max ). Oral administration of the capsule with a standard breakfast had no clinically meaningful effect on the bioavailability of aprepitant. The pharmacokinetics of aprepitant are non-linear across the clinical dose range. In healthy young adults, the increase in AUC 0 was 26% greater than dose proportional between 80-mg and 125-mg single doses administered in the fed state. Following oral administration of a single 125-mg dose of EMEND on Day 1 and 80 mg once daily on Days 2 and 3, the AUC 0 24hr was approximately 19.5 μg hr/ml and 20.1 μg hr/ml on Day 1 and Day 3, respectively. The C max of 1.5 μg/ml and 1.4 μg/ml were reached in approximately 4 hours (T max ) on Day 1 and Day 3, respectively. Distribution: Aprepitant is greater than 95% bound to plasma proteins. The geometric mean apparent volume of distribution at steady state (Vd ss ) is approximately 66 L in humans. EMEND (aprepitant capsules) Page 16 of 40

17 Aprepitant crosses the placenta in rats, and crosses the blood brain barrier in rats and ferrets. PET studies in humans indicate that aprepitant crosses the blood brain barrier (see ACTION AND CLINICAL PHARMACOLOGY). Metabolism: Aprepitant undergoes extensive metabolism. In healthy young adults, aprepitant accounts for approximately 24% of the radioactivity in plasma over 72 hours following a single oral 300-mg dose of [ 14 C]-aprepitant, indicating a substantial presence of metabolites in the plasma. Seven metabolites of aprepitant, which are only weakly active, have been identified in human plasma. The metabolism of aprepitant occurs largely via oxidation at the morpholine ring and its side chains. In vitro studies using human liver microsomes indicate that aprepitant is metabolized primarily by CYP3A4 with minor metabolism by CYP1A2 and CYP2C19, and no metabolism by CYP2D6, CYP2C9, or CYP2E1. Excretion: Aprepitant is eliminated primarily by metabolism; aprepitant is not renally excreted. Following administration of a single oral 300-mg dose of [ 14 C]-aprepitant to healthy subjects, 5% of the radioactivity was recovered in urine and 86% in feces. The apparent plasma clearance of aprepitant ranged from approximately 60 to 84 ml/min. The apparent terminal half-life ranged from approximately 9 to 13 hours. Pharmacodynamics Cardiac Electrophysiology: In a randomized, double-blind, positive-controlled, thorough QTc study, a single 200-mg dose of fosaprepitant (a prodrug of aprepitant) had no effect on the QTc interval. Special Populations and Conditions Pediatrics: The pharmacokinetics of EMEND 18 years of age. have not been evaluated in patients below Geriatrics: Following oral administration of a single 125-mg dose of EMEND on Day 1 and 80 mg once daily on Days 2 through 5, the AUC 0-24hr of aprepitant was 21% higher on Day 1 and 36% higher on Day 5 in elderly ( 65 years) relative to younger adults. The C max was 10% higher on Day 1 and 24% higher on Day 5 in elderly relative to younger adults. These differences are not considered clinically meaningful. No dosage adjustment for EMEND is necessary in elderly patients. Gender: Following oral administration of a single dose of EMEND, the AUC 0 24hr and C max for aprepitant are 9% and 17% higher, respectively, in females as compared with males. The half-life of aprepitant is approximately 25% lower in females as compared with males and its T max occurs at approximately the same time. No dosage adjustment for EMEND is necessary based on gender. Race: Following oral administration of a single dose of EMEND, there was no difference in the AUC 0 24hr or C max between Caucasians and Blacks. Single dose administration of oral aprepitant EMEND (aprepitant capsules) Page 17 of 40

18 in Hispanics resulted in a 27% and 19% increase in AUC 0 24hr and C max, respectively, as compared to Caucasians. Single dose administration of oral aprepitant in Asians resulted in a 74% and 47% increase in AUC 0 24hr and C max, respectively, as compared to Caucasians. These differences are not considered clinically meaningful. No dosage adjustment is necessary based on race. Body Mass Index (BMI): For every 5 kg/m 2 increase in BMI, AUC 0 24h decreased by 8.5% and C max decreased by 10.2%. These differences are not considered clinically meaningful. No dosage adjustment is necessary based on BMI. Hepatic Insufficiency: EMEND was well tolerated in patients with mild to moderate hepatic insufficiency. Following administration of a single 125-mg dose of EMEND on Day 1 and 80 mg once daily on Days 2 and 3 to patients with mild hepatic insufficiency (Child-Pugh score 5 to 6), the AUC 0 24hr of aprepitant was 11% lower on Day 1 and 36% lower on Day 3, as compared with healthy subjects given the same regimen. In patients with moderate hepatic insufficiency (Child-Pugh score 7 to 9), the AUC 0 24hr of aprepitant was 10% higher on Day 1 and 18% higher on Day 3, as compared with healthy subjects given the same regimen. These differences in AUC 0-24hr are not considered clinically meaningful; therefore, no dosage adjustment for EMEND is necessary in patients with mild to moderate hepatic insufficiency. There are no clinical or pharmacokinetic data in patients with severe hepatic insufficiency (Child- Pugh score >9). Renal Insufficiency: A single 240-mg dose of EMEND was administered to patients with severe renal insufficiency (CrCl<30 ml/min) and to patients with end stage renal disease (ESRD) requiring hemodialysis. In patients with severe renal insufficiency, the AUC 0 of total aprepitant (unbound and protein bound) decreased by 21% and C max decreased by 32%, relative to healthy subjects. In patients with ESRD undergoing hemodialysis, the AUC 0 of total aprepitant decreased by 42% and C max decreased by 32%. Due to modest decreases in protein binding of aprepitant in patients with renal disease, the AUC of pharmacologically active unbound drug was not significantly affected in patients with renal insufficiency compared with healthy subjects. Hemodialysis conducted 4 or 48 hours after dosing had no significant effect on the pharmacokinetics of aprepitant; less than 0.2% of the dose was recovered in the dialysate. No dosage adjustment for EMEND is necessary for patients with severe renal insufficiency or for patients with ESRD undergoing hemodialysis. STORAGE AND STABILITY Blisters: Store at room temperature (15 C 30 C) in the original package. EMEND (aprepitant capsules) Page 18 of 40

19 DOSAGE FORMS, COMPOSITION AND PACKAGING Tri-Pack which contains 2 capsules of EMEND 80 mg and 1 capsule of EMEND 125 mg. EMEND 80 mg capsules are white, opaque hard gelatin capsules with 461 and 80 mg printed radially in black ink. Available in blister packages of 2 and 6 capsules. EMEND 125 mg capsules are opaque, hard gelatin capsules with white body and pink cap with 462 and 125 mg printed radially in black ink. Available in blister packages of 6 capsules. Active ingredients: each capsule of EMEND for oral administration contains either 80 mg or 125 mg of aprepitant. Inactive ingredients: Each capsule of EMEND contains the following inactive ingredients: sucrose, microcrystalline cellulose, hydroxypropyl cellulose and sodium lauryl sulfate. The capsule shell excipients are gelatin and titanium dioxide. The 125-mg capsule shell also contains red ferric oxide and yellow ferric oxide. EMEND (aprepitant capsules) Page 19 of 40

20 PART II: SCIENTIFIC INFORMATION PHARMACEUTICAL INFORMATION Drug Substance Proper name: Aprepitant Chemical name: Aprepitant is a structurally novel substance P neurokinin 1 (NK 1 ) receptor antagonist, chemically described as 5- [[(2R,3S)-2-[(1R)-1-[3,5-bis(trifluoromethyl)phenyl] ethoxy]-3-(4-fluorophenyl)-4-morpholinyl]methyl]-1,2- dihydro-3h-1,2,4-triazol-3-one. Molecular formula: C 23 H 21 F 7 N 4 O 3 Molecular mass: Structural formula: O NH NH N N O O CH 3 CF 3 CF 3 F Physicochemical properties: Description: Aprepitant is a white to off-white crystalline solid. Solubilities: It is practically insoluble in water. Aprepitant is sparingly soluble in ethanol and isopropyl acetate and slightly soluble in acetonitrile. CLINICAL TRIALS Oral administration of EMEND (aprepitant) in combination with ondansetron and dexamethasone has been shown to prevent nausea and vomiting associated with highly and moderately emetogenic chemotherapy in well-controlled clinical studies. EMEND (aprepitant capsules) Page 20 of 40

21 Highly Emetogenic Chemotherapy Study Demographics and Trial Design Table 7 Summary of patient demographics for clinical trials in highly emetogenic chemotherapy Study # Trial design Dosage, route of administration and duration Study subjects (n=number) Mean age (Range) Gender 052* Randomized, doubleblind, placebocontrolled, parallelgroup EMEND 125 mg on Day 1 and 80 mg/day on Days 2 and 3 in combination with ondansetron 32 mg IV on Day 1 and dexamethasone 12 mg on Day 1 and 8 mg once daily on Days 2 through 4. OR Standard therapy which consisted of placebo in combination with ondansetron 32 mg IV on Day 1 and dexamethasone 20 mg on Day 1 and 8 mg twice daily on Days 2 through Male Female 054* Randomized, doubleblind, placebocontrolled, parallelgroup EMEND 125 mg on Day 1 and 80 mg/day on Days 2 and 3 in combination with ondansetron 32 mg IV on Day 1 anddexamethasone 12 mg on Day 1 and 8 mg once daily on Days 2 through 4. OR Standard therapy which consisted of placebo in combination with ondansetron 32 mg IV on Day 1 and dexamethasone 20 mg on Day 1 and 8 mg twice daily on Days 2 through Male Female *Although a 32 mg IV dose of ondansetron was used in clinical trials, this is no longer a recommended dose due to the dose-dependent risk of QTc prolongation (see the package insert for ondansetron for additional details). EMEND (aprepitant capsules) Page 21 of 40

22 Studies 052 and 054 In the above clinical studies, all enrolled patients received high-dose cisplatin 70 mg/m 2. Approximately 95% of the patients in the aprepitant group received a concomitant chemotherapeutic agent. The most common chemotherapeutic agents and the number of aprepitant patients exposed follows: etoposide (106), fluorouracil (100), gemcitabine (89), vinorelbine (82), paclitaxel (52), cyclophosphamide (50), doxorubicin (38), docetaxel (11). The efficacy of EMEND has not been investigated in highly emetogenic chemotherapy clinical trials without cisplatin. The antiemetic activity of EMEND was evaluated during the acute phase (0 to 24 hours postcisplatin treatment), the delayed phase (25 to 120 hours post-cisplatin treatment) and overall (0 to 120 hours post-cisplatin treatment) in Cycle 1. Efficacy was based on evaluation of the following endpoints: Primary endpoint: complete response (defined as no emetic episodes and no use of rescue therapy) Other prespecified endpoints: complete protection (defined as no emetic episodes, no use of rescue therapy, and a maximum nausea visual analogue scale [VAS] score <25 mm on a 0 to 100 mm scale) no emesis (defined as no emetic episodes regardless of use of rescue therapy) no nausea (maximum VAS <5 mm on a 0 to 100 mm scale) no significant nausea (maximum VAS <25 mm on a 0 to 100 mm scale) A summary of the key study results from each individual study analysis is shown in Table 8 and in Table 9. EMEND (aprepitant capsules) Page 22 of 40

23 Study Results Table 8 Percent of patients receiving highly emetogenic chemotherapy responding by treatment group and phase for study 1 Cycle 1 ENDPOINTS p-value PRIMARY ENDPOINT Aprepitant Regimen (N=260) % Standard Therapy (N=261) % Complete Response Overall <0.001 OTHER PRESPECIFIED ENDPOINTS Complete Response Acute phase 89 Delayed phase 75 Complete Protection Overall Acute phase Delayed phase No Emesis Overall Acute phase Delayed phase No Nausea Overall Delayed phase No Significant Nausea Overall Delayed phase N: Number of patients (older than 18 years of age) who received cisplatin, study drug, and had at least one post-treatment efficacy evaluation. Overall: 0 to 120 hours post-cisplatin treatment. Acute phase: 0 to 24 hours post-cisplatin treatment. Delayed phase: 25 to 120 hours post-cisplatin treatment. * Not statistically significant when adjusted for multiple comparisons. ** Not statistically significant. Visual analogue scale (VAS) score range: 0 mm = no nausea; 100 mm = nausea as bad as it could be <0.001 < NS* <0.001 < <0.001 NS** NS** NS** NS** EMEND (aprepitant capsules) Page 23 of 40

24 Table 9 Percent of patients receiving highly emetogenic chemotherapy responding by treatment group and phase for study 2 Cycle 1 ENDPOINTS p-value PRIMARY ENDPOINT Aprepitant Regimen (N=261) % Standard Therapy (N=263) % Complete Response Overall <0.001 OTHER PRESPECIFIED ENDPOINTS Complete Response Acute phase 83 Delayed phase 68 Complete Protection Overall Acute phase Delayed phase <0.001 <0.001 <0.001 <0.001 <0.001 No Emesis Overall Acute phase Delayed phase <0.001 <0.001 <0.001 No Nausea Overall Delayed phase NS* NS* No Significant Nausea Overall Delayed phase N: Number of patients (older than 18 years of age) who received cisplatin, study drug, and had at least one post-treatment efficacy evaluation. Overall: 0 to 120 hours post-cisplatin treatment. Acute phase: 0 to 24 hours post-cisplatin treatment. Delayed phase: 25 to 120 hours post-cisplatin treatment. * Not statistically significant when adjusted for multiple comparisons. ** Not statistically significant. Visual analogue scale (VAS) score range: 0 mm = no nausea; 100 mm = nausea as bad as it could be. NS** NS** In both studies, a statistically significantly higher proportion of patients receiving the aprepitant regimen in Cycle 1 had a complete response (primary endpoint), compared with patients receiving standard therapy. A statistically significant difference in complete response in favor of the aprepitant regimen was also observed when the acute phase and the delayed phase were analyzed separately. In both studies, the estimated time to first emesis after initiation of cisplatin treatment was longer with the aprepitant regimen, and the incidence of first emesis was reduced in the aprepitant regimen group compared with standard therapy group as depicted in the Kaplan-Meier curves in Figure 1. EMEND (aprepitant capsules) Page 24 of 40

25 Figure 1 Percent of patients receiving highly emetogenic chemotherapy who remain emesis free over time Cycle 1 Percent of Patients Study 1 Aprepitant Regimen (N=260) Standard Therapy (N=261) Hours p-value <0.001 based on a log rank test for Study 1 and Study 2; nominal p-values not adjusted for multiplicity Study 2 Aprepitant Regimen (N=261) Standard Therapy (N=263) Patient-Reported Outcomes: The impact of nausea and vomiting on patients daily lives was assessed in Cycle 1 of both Phase III studies using the Functional Living Index Emesis (FLIE), a validated nausea and vomiting-specific patient-reported outcome measure. Minimal or no impact of nausea and vomiting on patients daily lives is defined as a FLIE total score >108. In each of the 2 studies, a higher proportion of patients receiving the aprepitant regimen reported minimal or no impact of nausea and vomiting on daily life (Study 1: 74% versus 64%; Study 2: 75% versus 64%). Multiple-Cycle Extension: In the same 2 clinical studies, 851 patients continued into the Multiple-Cycle extension for up to 6 cycles of chemotherapy. The efficacy of the aprepitant regimen was maintained during all cycles. EMEND (aprepitant capsules) Page 25 of 40

26 Moderately Emetogenic Chemotherapy Study Demographics and Trial Design Table 10 Summary of patient demographics for clinical trials in moderately emetogenic chemotherapy Study # Trial design Dosage, route of administration and duration Study subjects (n=number) Mean age (Range) Gender 071 Randomized, doubleblind, parallel-group, standard therapy EMEND 125 mg on Day 1 and 80 mg/day on Days 2 and 3 in combination with ondansetron 8 mg orally twice on Day 1 plus dexamethasone 12 mg orally on Day 1. Standard Therapy consisted of placebo in combination with ondansetron 8 mg orally (twice on Day 1, and every 12 hours on Days 2 and 3) plus dexamethasone 20 mg orally on Day 1. EMEND 125 mg on Day 1 and 80 mg/day on Days 2 and 3 in combination with ondansetron 8 mg orally twice on Day 1 plus dexamethasone 12 mg orally on Day 1. Standard Therapy consisted of placebo in combination with ondansetron 8 mg orally (twice on Day 1, and every 12 hours on Days 2 and 3) plus dexamethasone 20 mg orally on Day (23 78) Female: 864 Male: Randomized, Double- Blind, Parallel-Group Study Conducted Under In-House Blinding Conditions (19 87) Female: 652 Male: 196 EMEND (aprepitant capsules) Page 26 of 40

27 Study 071 The first MEC study (P071) enrolled breast cancer patients (99% women) receiving a chemotherapy regimen that included cyclophosphamide mg/m 2 ; or cyclophosphamide mg/m 2 and doxorubicin ( 60 mg/m 2 ) or epirubicin ( 100 mg/m 2 ). Some patients also received other chemotherapeutic agents such as fluorouracil, methotrexate, docetaxel or paclitaxel. In this study (P071), the most common combinations were cyclophosphamide + doxorubicin (60.6%); and cyclophosphamide + epirubicin + fluorouracil (21.6%). In the first MEC study (P071), the antiemetic activity of EMEND was evaluated during the acute phase (0 to 24 hours post-chemotherapy treatment), the delayed phase (25 to 120 hours post-chemotherapy treatment) and overall (0 to 120 hours post-chemotherapy treatment) in Cycle 1. The antiemetic activity of EMEND was evaluated based on the following endpoints: Primary endpoint: complete response (defined as no emetic episodes and no use of rescue therapy) in the overall phase (0 to 120 hours post-chemotherapy) Other prespecified endpoints: no emesis (defined as no emetic episodes regardless of use of rescue therapy) no nausea (maximum VAS <5 mm on a 0 to 100 mm scale) no significant nausea (maximum VAS <25 mm on a 0 to 100 mm scale) complete protection (defined as no emetic episodes, no use of rescue therapy, and a maximum nausea visual analogue scale [VAS] score <25 mm on a 0 to 100 mm scale) complete response during the acute and delayed phases A summary of the key results from this study is shown in Table 11. EMEND (aprepitant capsules) Page 27 of 40

28 Study Results Table 11 Percent of patients receiving moderately emetogenic chemotherapy responding by treatment group and phase Cycle 1 ENDPOINTS p-value PRIMARY ENDPOINT Aprepitant Regimen (N=433) % Standard Therapy (N=424) % Complete Response OTHER PRESPECIFIED ENDPOINTS No Emesis NS* No Nausea NS No Significant Nausea NS No Rescue Therapy NS Complete Protection NS N: Number of patients included in the primary analysis of complete response. Overall: 0 to 120 hours post-chemotherapy treatment. * NS when adjusted for prespecified multiple comparisons rule; unadjusted p-value < In this study, a statistically significantly (p=0.015) higher proportion of patients receiving the aprepitant regimen (51%) in Cycle 1 had a complete response (primary endpoint) during the overall phase compared with patients receiving standard therapy (42%). The difference between treatment groups was primarily driven by the ''No Emesis Endpoint'', a principal component of this composite primary endpoint. In addition, a higher proportion of patients receiving the aprepitant regimen in Cycle 1 had a complete response during the acute (0 24 hours) and delayed ( hours) phases compared with patients receiving standard therapy; however, the treatment group differences failed to reach statistical significance, after multiplicity adjustments. Patient-Reported Outcomes: In a phase III study in patients receiving moderately emetogenic chemotherapy, the impact of nausea and vomiting on patients' daily lives was assessed in Cycle 1 using the FLIE. A higher proportion of patients receiving the aprepitant regimen reported minimal or no impact on daily life (64% versus 56%). This difference between treatment groups was primarily driven by the ''No Vomiting Domain'' of this composite endpoint. Multiple-Cycle Extension: A total of 744 patients receiving moderately emetogenic cancer chemotherapy continued into the Multiple-Cycle extension for up to 4 cycles of chemotherapy. The efficacy of the aprepitant regimen was maintained during all cycles. Study 130 In a second multicenter, randomized, double-blind, parallel-group, clinical study (130), the aprepitant regimen was compared with standard therapy in 848 patients receiving a chemotherapy regimen that included any IV dose of oxaliplatin, carboplatin, epirubicin, idarubicin, ifosfamide, irinotecan, daunorubicin, doxorubicin; cyclophosphamide IV (<1500 mg/m 2 ); or cytarabine IV (>1 g/m 2 ). Patients who were randomized to receive the aprepitant regimen consisted of EMEND (aprepitant capsules) Page 28 of 40

29 76% women and 24% men. Patients receiving the aprepitant regimen were receiving chemotherapy for a variety of tumor types including 52% with breast cancer, 21% with gastrointestinal cancers including colorectal cancer, 13% with lung cancer and 6% with gynecological cancers. In this study, 48% of patients received AC therapy, defined as anthracycline (doxorubicin, epirubicin) + cyclophosphamide chemotherapy regimen, and 52% received non-ac therapy. The aprepitant regimen consisted of EMEND 125 mg on Day 1 and 80 mg/day on Days 2 and 3 in combination with ondansetron 8 mg orally twice on Day 1 plus dexamethasone 12 mg orally on Day 1. Standard therapy consisted of placebo in combination with ondansetron 8 mg orally (twice on Day 1, and every 12 hours on Days 2 and 3) plus dexamethasone 20 mg orally on Day 1. The antiemetic activity of EMEND was evaluated during the overall phase (0 to 120 hours postchemotherapy treatment) in Cycle 1. Efficacy was based on the evaluation of the following endpoints: Primary endpoint: no vomiting in the overall period (0 to 120 hours post-chemotherapy) Other prespecified endpoints: complete response (defined as no vomiting and no use of rescue therapy) in the overall period (0 to 120 hours post-chemotherapy) time to first vomiting episode overall (0 to 120 hours post-chemotherapy) no vomiting Acute (0 to 24 hours following initiation of chemotherapy infusion) and Delayed (25 to 120 hours following initiation of chemotherapy infusion) complete response Acute and Delayed, as defined above no use of rescue therapy Overall, Acute, and Delayed, as defined above no Impact on Daily Life (Functional Living Index-Emesis [FLIE] total score >108) Overall, as defined above no vomiting and no significant nausea (VAS <25 mm) Overall, as defined above A summary of the key study results is shown in Table 12. EMEND (aprepitant capsules) Page 29 of 40

30 Table 12 Percent of Patients Receiving Moderately Emetogenic Chemotherapy Responding by Treatment Group and Phase for Study 2 Cycle 1 ENDPOINTS Aprepitant Regimen (N=430) % Standard Therapy (N=418) % p-value PRIMARY ENDPOINT No Vomiting Overall < KEY SECONDARY ENDPOINT Complete Response Overall OTHER SECONDARY ENDPOINTS No Vomiting Acute phase Delayed phase No Impact on Daily Life (FLIE total score >108) Overall Complete Response Acute phase Delayed phase No Use of Rescue Therapy Overall Acute phase Delayed phase ß ß ß No Vomiting and No Significant Nausea (VAS <25 mm) Overall N = Number of patients who received chemotherapy treatment, study drug, and had at least one post-treatment efficacy evaluation. ß Not statistically significant after adjustment for multiplicity. Visual analogue scale (VAS) score range: 0 mm = no nausea; 100 mm = nausea as bad as it could be. In this study, a statistically significantly (p<0.0001) higher proportion of patients receiving the aprepitant regimen (76%) in Cycle 1 had no vomiting (primary endpoint) during the overall phase compared with patients receiving standard therapy (62%). In addition, a higher proportion of patients receiving the aprepitant regimen in Cycle 1 had a complete response in the overall phase (0 120 hours) compared with patients receiving standard therapy. Aprepitant was numerically superior versus standard therapy regardless of age, gender, chemotherapy regimen, or tumor type (breast, gastrointestinal, lung or other) as assessed by the No Vomiting and Complete Response endpoints. However, the proportion of patients with no vomiting and complete response in the standard therapy group, as well as the size of the difference in no vomiting and complete response between the treatment groups, differed by gender and EMEND (aprepitant capsules) Page 30 of 40

31 chemotherapy regimen. During the overall phase, complete response to the aprepitant regimen and standard therapy, respectively, was reached in 209/324 (65%) and 161/320 (50%) in women and 83/101 (82%) and 68/87 (78%) of men. No vomiting in the aprepitant regimen and standard therapy, respectively, was reached in 235/324 (73%) and 181/319 (57%) in women and 89/101 (88%) and 71/87 (82%) in men. During the overall phase, complete response to the aprepitant regimen and standard therapy, respectively, was reached in 125/199 (63%) and 96/204 (47%) in AC therapy and 167/226 (74%) and 133/203 (66%) in non-ac therapy. No vomiting in the aprepitant regimen and standard therapy, respectively, was reached in 136/199 (68%) and 108/204 (53%) in AC-therapy and 188/226 (83%) and 144/202 (71%) in non-ac therapy. In this study, the estimated time to first vomiting after initiation of chemotherapy treatment was longer with the aprepitant regimen, and the incidence was reduced in the aprepitant regimen group compared with standard therapy group as depicted in the Kaplan-Meier curves in Figure 2. Figure 2 Kaplan-Meier Curves for Time to First Vomiting Episode From Start of Chemotherapy Administration in the Overall Phase Cycle 1 (Full Analysis Set Patient Population) In this study, a statistically significantly higher proportion of patients receiving the aprepitant regimen in Cycle 1 reported no impact of nausea and vomiting on daily life, as measured by a FLIE total score >108, compared with patients receiving standard therapy. DETAILED PHARMACOLOGY Dexamethasone: EMEND, when given as a regimen of 125 mg with dexamethasone coadministered orally as 20 mg on Day 1, and EMEND when given as 80 mg/day with dexamethasone coadministered orally as 8 mg on Days 2 through 5, increased the AUC of dexamethasone, a CYP3A4 substrate by 2.2-fold, on Days 1 and 5. The usual oral dexamethasone doses should be reduced by approximately 50% when coadministered with EMEND, to achieve exposures of dexamethasone similar to those obtained when it is given without EMEND. The daily dose of dexamethasone administered in clinical studies with EMEND reflects an approximate 50% reduction of the dose of dexamethasone (see DOSAGE AND ADMINISTRATION). EMEND (aprepitant capsules) Page 31 of 40

32 Methylprednisolone: EMEND, when given as a regimen of 125 mg on Day 1 and 80 mg/day on Days 2 and 3, increased the AUC of methylprednisolone, a CYP3A4 substrate, by 1.3-fold on Day 1 and by 2.5-fold on Day 3, when methylprednisolone was coadministered intravenously as 125 mg on Day 1 and orally as 40 mg on Days 2 and 3. The usual IV methylprednisolone dose should be reduced by approximately 25%, and the usual oral methylprednisolone dose should be reduced by approximately 50% when coadministered with EMEND, to achieve exposures of methylprednisolone similar to those obtained when it is given without EMEND. Warfarin: A single 125-mg dose of EMEND was administered on Day 1 and 80 mg/day on Days 2 and 3 to healthy subjects who were stabilized on chronic warfarin therapy. Although there was no effect of EMEND on the plasma AUC of R(+) or S(-) warfarin determined on Day 3, there was a 34% decrease in S(-) warfarin (a CYP2C9 substrate) trough concentration accompanied by a 14% decrease in the prothrombin time (reported as International Normalized Ratio or INR) 5 days after completion of dosing with EMEND. In patients on chronic warfarin therapy, the prothrombin time (INR) should be closely monitored in the 2-week period, particularly at 7 to 10 days, following initiation of the 3-day regimen of EMEND with each chemotherapy cycle (see WARNINGS AND PRECAUTIONS). Tolbutamide: EMEND, when given as 125 mg on Day 1 and 80 mg/day on Days 2 and 3, decreased the AUC of tolbutamide (a CYP2C9 substrate) by 23% on Day 4, 28% on Day 8, and 15% on Day 15, when a single dose of tolbutamide 500 mg was administered orally prior to the administration of the 3-day regimen of EMEND and on Days 4, 8, and 15. Oral contraceptives: Aprepitant, when given once daily for 14 days as a 100-mg capsule with an oral contraceptive containing 35 mcg of ethinyl estradiol and 1 mg of norethindrone, decreased the AUC of ethinyl estradiol by 43%, and decreased the AUC of norethindrone by 8%; therefore the efficacy of hormonal contraceptives during and for 28 days after administration of EMEND may be reduced. Alternative or back-up methods of contraception should be used during treatment with EMEND and for 1 month following the last dose of EMEND (see WARNINGS AND PRECAUTIONS). Midazolam: EMEND increased the AUC of midazolam, a sensitive CYP3A4 substrate, by 2.3- fold on Day 1 and 3.3-fold on Day 5, when a single oral dose of midazolam 2 mg was coadministered on Day 1 and Day 5 of a regimen of EMEND 125 mg on Day 1 and 80 mg/day on Days 2 through 5. The potential effects of increased plasma concentrations of midazolam or other benzodiazepines metabolized via CYP3A4 (alprazolam, triazolam) should be considered when coadministering these agents with EMEND. In another study with intravenous administration of midazolam, EMEND was given as 125 mg on Day 1 and 80 mg/day on Days 2 and 3, and midazolam 2 mg IV was given prior to the administration of the 3-day regimen of EMEND and on Days 4, 8, and 15. EMEND increased the AUC of midazolam by 25% on Day 4 and decreased the AUC of midazolam by 19% on Day 8 relative to the dosing of EMEND on Days 1 through 3. These effects were not considered clinically important. The AUC of midazolam on Day 15 was similar to that observed at baseline. EMEND (aprepitant capsules) Page 32 of 40

33 An additional study was completed with intravenous administration of midazolam and EMEND. Intravenous midazolam 2 mg was given 1 hour after oral administration of a single dose of EMEND 125 mg. The plasma AUC of midazolam was increased by 1.5-fold. Depending on clinical situations (e.g., elderly patients) and degree of monitoring available, dosage adjustment for intravenous midazolam may be necessary when it is coadministered with EMEND for the chemotherapy induced nausea and vomiting indication (125 mg on Day 1 followed by 80 mg on Days 2 and 3). Ketoconazole: When a single 125-mg dose of EMEND was administered on Day 5 of a 10-day regimen of 400 mg/day of ketoconazole, a strong CYP3A4 inhibitor, the AUC of aprepitant increased approximately 5-fold and the mean terminal half-life of aprepitant increased approximately 3-fold. Concomitant administration of EMEND with strong CYP3A4 inhibitors should be approached cautiously. Rifampin: When a single 375-mg dose of EMEND was administered on Day 9 of a 14-day regimen of 600 mg/day of rifampin, a strong CYP3A4 inducer, the AUC of aprepitant decreased approximately 11-fold and the mean terminal half-life decreased approximately 3-fold. Coadministration of EMEND with drugs that induce CYP3A4 activity may result in reduced plasma concentrations and decreased efficacy of EMEND. Diltiazem: In patients with mild to moderate hypertension, administration of aprepitant once daily, as a tablet formulation comparable to 230 mg of the capsule formulation, with diltiazem 120 mg 3 times daily for 5 days, resulted in a 2-fold increase of aprepitant AUC and a simultaneous 1.7-fold increase of diltiazem AUC. These pharmacokinetic effects did not result in clinically meaningful changes in ECG, heart rate, or blood pressure beyond those changes induced by diltiazem alone. Paroxetine: Coadministration of once daily doses of aprepitant, as a tablet formulation comparable to 85 mg or 170 mg of the capsule formulation, with paroxetine 20 mg once daily, resulted in a decrease in AUC by approximately 25% and C max by approximately 20% of both aprepitant and paroxetine. TOXICOLOGY Animal Toxicology Acute Toxicity The approximate oral LD 50 of aprepitant was >2000 mg/kg in female mice and rats. The approximate intraperitoneal LD 50 of aprepitant was >800 mg/kg, but <2000 mg/kg in female rats and >2000 mg/kg in female mice. EMEND (aprepitant capsules) Page 33 of 40

34 Chronic Toxicity The toxicity potential of aprepitant was evaluated in a series of repeated-dose oral toxicity studies in rats and in dogs for up to 1 year. In rats, oral administration of aprepitant for 6 months at doses up to the maximum feasible dose of 1000 mg/kg twice daily (approximately equivalent to [females] or lower than [males] the adult human dose based on systemic exposure) produced increased hepatic weights that correlated with hepatocellular hypertrophy, increased thyroidal weights that correlated with thyroid follicular cell hypertrophy and/or hyperplasia, and pituitary cell vacuolation. These findings are a speciesspecific consequence of hepatic CYP enzyme induction in the rat, and are consistent with changes observed in rats with other structurally and pharmacologically dissimilar compounds that have been shown to induce hepatic CYP enzymes. In dogs administered aprepitant orally for 9 months at doses 5 mg/kg twice daily (greater than or equal to 13 times the adult human dose based on systemic exposure), toxicity was characterized by slight increases in serum alkaline phosphatase activity and decreases in the albumin/globulin ratio. Significantly decreased body weight gain, testicular degeneration, and prostatic atrophy were observed at doses 25 mg/kg twice daily (greater than or equal to 31 times the adult human dose based on systemic exposure). A slight increase in hepatic weights with no histologic correlate was seen at 500 mg/kg twice daily (70 times the adult human dose based on systemic exposure). No toxicity was observed in dogs administered 32 mg/kg/day (6 times the adult human dose based on systemic exposure) for 1 year. Carcinogenesis Carcinogenicity studies were conducted in mice and rats for approximately 2 years. In mice, aprepitant was not carcinogenic at doses up to 500 mg/kg/day (approximately 2 times the adult human dose based on systemic exposure). Rats developed hepatocellular adenomas at a dose of 25 mg/kg twice daily (females) and 125 mg/kg twice daily (females and males), thyroid follicular cell adenomas at a dose of 125 mg/kg twice daily (females and males), and thyroid follicular cell carcinomas at a dose of 125 mg/kg twice daily (males). Systemic exposures at these doses in rats were approximately equivalent to or lower than exposures in humans at the recommended dose. Tumors of these types are a species-specific consequence of hepatic CYP enzyme induction in the rat, and are consistent with changes observed in rats with other structurally and pharmacologically dissimilar compounds that have been shown to induce hepatic CYP enzymes. Mutagenesis Aprepitant was neither mutagenic nor genotoxic in assays conducted to detect mutagenicity, DNA strand breaks, and chromosomal aberrations. Aprepitant was negative in the in vitro microbial and TK6 human lymphoblastoid cell mutagenesis assays, the in vitro alkaline elution/rat hepatocyte DNA strand break test, the in vitro chromosomal aberration assay in Chinese hamster ovary cells, and the in vivo mouse micronucleus assay in bone marrow. EMEND (aprepitant capsules) Page 34 of 40

35 Reproduction Aprepitant administered to female rats at doses up to the maximum feasible dose of 1000 mg/kg twice daily (approximately equivalent to the adult human dose based on systemic exposure) had no effects on mating performance, fertility, or embryonic/fetal survival. Administration of aprepitant to male rats at doses up to the maximum feasible dose of 1000 mg/kg twice daily (lower than the adult human dose based on systemic exposure) produced no effects on mating performance, fertility, embryonic/fetal survival, sperm count and motility, testicular weights, or the microscopic appearance of the testes and epididymides. Development In rats and rabbits administered oral doses of aprepitant up to 1000 mg/kg twice daily and 25 mg/kg/day, respectively (up to 1.5 times the systemic exposure at the adult human dose), there was no evidence of developmental toxicity as assessed by embryonic/fetal survival, fetal body weight, and fetal external, visceral, and skeletal morphology. Placental transfer of aprepitant occurred in rats and rabbits at these doses. Concentrations of aprepitant in fetal plasma were approximately 27% and 56% of maternal plasma concentrations in rats and rabbits, respectively. Significant concentrations of aprepitant were observed in the milk of lactating rats administered 1000 mg/kg twice daily. At this dose, the mean milk drug concentration was 90% of the mean maternal plasma concentration. EMEND (aprepitant capsules) Page 35 of 40

36 REFERENCES 1) MRL Clinical Study Report: A Randomized, Double-Blind, Placebo-Controlled, Parallel- Group Study, Conducted Under In-House Blinding Conditions, to Examine the Safety, Tolerability, and Efficacy of MK 0869 for the Prevention of Chemotherapy-Induced Nausea and Vomiting Associated With High-Dose Cisplatin (Protocol 052) 2) MRL Clinical Study Report: A Randomized, Double-Blind, Placebo-Controlled, Parallel- Group Study, Conducted Under In-House Blinding Conditions, to Examine the Safety, Tolerability, and Efficacy of MK 0869 for the Prevention of Chemotherapy-Induced Nausea and Vomiting Associated With High-Dose Cisplatin (Protocol 054) 3) MRL Clinical Study Report, Multicenter Study: A Randomized, Double-Blind, Parallel- Group Study Conducted Under In-House Blinding Conditions to Determine the Efficacy and Tolerability of Aprepitant for the Prevention of Chemotherapy-Induced Nausea and Vomiting Associated With Moderately Emetogenic Chemotherapy (Protocol 071) 4) MRL Clinical Study Report, A Randomized, Double-Blind, Parallel-Group Study Conducted Under In-House Blinding Conditions to Determine the Efficacy and Tolerability of Aprepitant for the Prevention of Chemotherapy-Induced Nausea and Vomiting Associated With Moderately Emetogenic Chemotherapy (Protocol 130). 5) de Wit R, Herrstedt J, Rapoport B, Carides AD, Guoguang-Ma J, Elmer M et al. The oral NK(1) antagonist, aprepitant, given with standard antiemetics provides protection against nausea and vomiting over multiple cycles of cisplatin-based chemotherapy: a combined analysis of two randomised, placebo-controlled phase III clinical trials. Eur J Cancer 2004;40: ) Gralla RJ, de Wit R, Herrstedt J. Carides AD, Ianus J, Guoguang-Ma J et al. Antiemetic Efficacy of the Neurokinin-1 Antagonist, Aprepitant, Plus a 5HT3 Antagonist and a Corticosteroid in Patients Receiving Anthracyclines or Cyclophosphamide in Addition to High-Dose Cisplatin. Cancer 2005 Aug 15;104(4): ) Hesketh PJ, Grunberg SM, Gralla RJ, Warr DG, Roila F, de Wit R et al. The oral neurokinin-1 antagonist aprepitant for the prevention of chemotherapy-induced nausea and vomiting: a multinational, randomized, double-blind, placebo-controlled trial in patients receiving highdose cisplatin the Aprepitant Protocol 052 Study Group. J Clin Oncol 2003;21: ) Hesketh PJ, Grunberg, SM, Herrstedt J, de Wit R, Gralla RJ, Carides AD. Combined data from two phase III trials of the NK1 antagonist aprepitant plus a 5HT3 antagonist and a corticosteroid for prevention of chemotherapy-induced nausea and vomiting: effect of gender on treatment response. Support Care Cancer 2006;14: EMEND (aprepitant capsules) Page 36 of 40

37 9) Poli-Bigelli S, Rodrigues-Pereira J, Carides AD, Guoguang-Ma J, Eldridge K, Hipple A et al. Addition of the neurokinin 1 receptor antagonist aprepitant to standard antiemetic therapy improves control of chemotherapy-induced nausea and vomiting. Results from a randomized, double-blind, placebo-controlled trial in Latin America. Cancer 2003;97: ) Rapoport BL, Jordan K, Boice JA, Taylor A, Brown C, Hardwick JS et al. Aprepitant for the prevention of chemotherapy-induced nausea and vomiting associated with a broad range of moderately emetogenic chemotherapies and tumor types: a randomized, double blind study. Support Care Cancer 2009 Jul 01; published on line. 11) Warr DG, Hesketh PJ, Gralla RJ, Muss HB, Herrstedt J, Eisenbert PD et al. Efficacy and tolerability of aprepitant for the prevention of chemotherapy-induced nausea and vomiting in patients with breast cancer after one cycle of moderately emetogenic chemotherapy. J Clin Oncol 2005;23: EMEND (aprepitant capsules) Page 37 of 40

38 IMPORTANT: PLEASE READ PART III: CONSUMER INFORMATION EMEND aprepitant capsules This leaflet is part III of a three-part "Product Monograph" published when EMEND was approved for sale in Canada and is designed specifically for Consumers. This leaflet is a summary and will not tell you everything about EMEND. Contact your physician or pharmacist if you have any questions about the drug. Please read this leaflet carefully before you start to take your medicine, even if you have just refilled your prescription. Some of the information in the previous leaflet may have changed. Remember that your physician has prescribed this medicine only for you. Never give it to anyone else. ABOUT THIS MEDICATION What the medication is used for: EMEND, in combination with 5-HT 3 antagonists and dexamethasone, is indicated for the prevention of nausea and vomiting associated with your cancer chemotherapy treatment. What it does: EMEND is a member of a new class of medicines called neurokinin 1 (NK 1 ) receptor antagonists. EMEND works by blocking neurokinin, a substance in the brain that causes nausea and vomiting. When it should not be used: Do not take EMEND if you are allergic to any of its ingredients. Do not take EMEND with pimozide, terfenadine, astemizole, or cisapride. Taking EMEND with these medications could result in serious or life-threatening problems. What the medicinal ingredient is: Aprepitant What the important non-medicinal ingredients are: Gelatin, hydroxypropyl cellulose, microcrystalline cellulose sodium lauryl sulfate, sucrose and titanium dioxide. The 125 mg capsule shell also contains red ferric oxide and yellow ferric oxide. What dosage forms it comes in: Each capsule contains 80 mg or 125 mg of aprepitant. WARNINGS AND PRECAUTIONS Serious Warnings and Precautions Drug interactions with: Medicines that are likely to be broken down mainly by the liver Warfarin Hormonal contraception (birth control medicines) BEFORE you use EMEND talk to your physician or pharmacist if: you have any past or present medical problems you have liver problems you have any allergies you drive a car or operate machinery you are pregnant or plan to become pregnant you are breast-feeding or plan to breast-feed Use in children EMEND should not be given to children under 18 years of age. Use in the elderly No dosage adjustment is necessary. INTERACTIONS WITH THIS MEDICATION Tell your physician about all medicines that you are taking or plan to take, even those you can get without a prescription or herbal products. Your physician may check that your medicines are working properly together if you are taking other medicines such as: anti-anxiety drugs (such as alprazolam, midazolam) birth control medicines (which may not work as well) ketoconazole (an antifungal) rifampin (an antibiotic) paroxetine (a medicine used to treat a certain type of depression) diltiazem (a medicine used to treat high blood pressure) dexamethasone, methylprednisolone (steroid medicines used for a variety of conditions) warfarin (a blood thinner) tolbutamide (a medicine used to treat diabetes) phenytoin (a medicine used to treat seizures) some chemotherapy medications such as ifosfamide PROPER USE OF THIS MEDICATION Usual dose: Take EMEND exactly as your physician has prescribed. The recommended dose of EMEND is one 125 mg capsule by mouth 1 hour before you start your chemotherapy treatment on Day 1 and one 80 mg capsule by mouth each morning for the 2 days following your chemotherapy treatment. EMEND may be taken with or without food. EMEND (aprepitant capsules) Page 38 of 40